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Discussion Papers present results of country analysis or research that are circulated to encourage discussion and comment within the development community. To present these results with the least possible delay, the typescript of this paper has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors. Some sources cited in this paper may be informal documents that are not readily available. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent. The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility whatsoever for any consequence of their use. The boundaries, colors, denominations, and other information shown on any map in this volume do not imply on the part of the World Bank Group any judgment on the legal status of any territory or the endorsement or acceptance of such boundaries
"Poverty, Social Services, and Safety Nets in Vietnam" "Poverty, Social Services, and Safety Nets in Vietnam" Poverty, Social Services, And Safety Nets In Vietnam Nicholas Prescott The World Bank Washington, D.C Copyright © 1997 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W Washington, D.C 20433, U.S.A All rights reserved Manufactured in the United States of America First printing October 1997 Discussion Papers present results of country analysis or research that are circulated to encourage discussion and comment within the development community To present these results with the least possible delay, the typescript of this paper has not been prepared in accordance with the procedures appropriate to formal printed texts, and the World Bank accepts no responsibility for errors Some sources cited in this paper may be informal documents that are not readily available The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or the countries they represent The World Bank does not guarantee the accuracy of the data included in this publication and accepts no responsibility whatsoever for any consequence of their use The boundaries, colors, denominations, and other information shown on any map in this volume not imply on the part of the World Bank Group any judgment on the legal status of any territory or the endorsement or acceptance of such boundaries The material in this publication is copyrighted Requests for permission to reproduce portions of it should be sent to the Office of the Publisher at the address shown in the copyright notice above The World Bank encourages dissemination of its work and will normally give permission promptly and, when the reproduction is for noncommercial purposes, without asking a fee Permission to copy portions for classroom use is granted through the Copyright Clearance Center, Inc., Suite 910, 222 Rosewood Drive, Danvers, Massachusetts 01923, U.S.A The complete backlist of publications from the World Bank is shown in the annual Index of Publications , which contains an alphabetical title list with full ordering information The latest edition is available free of charge from the Distribution Unit, Office of the Publisher, The World Bank, 1818 H Street, N.W., Washington, D.C 20433, U.S.A., or from Publications, The World Bank, 66, avenue d'Iena, 75116 Paris, France ISSN: 0259−210X Nicholas Prescott is senior economist in the World Bank's East Asia and Pacific Region Library of Congress Cataloging−in−Publication Data Poverty, Social Services, And Safety Nets In Vietnam "Poverty, Social Services, and Safety Nets in Vietnam" Prescott, Nicholas M Poverty, social services, and safety nets in Vietnam / Nicholas M Prescott p c — (World Bank discussion paper; no 376) ISBN 0−8213−4024−7 Human services—Vietnam Human services—Vietnam—Finance Public welfare—Vietnam Poor—Services for—Vietnam Vietnam—Social policy I Title II Series: World Bank discussion papers; 376 HV400.5.P74 1997 362.5'8'09597—dc21 97−28972 CIP Contents Foreword link Abstract link Introduction link Education link Falling School Enrollments link Access by the Poor link Changing Role of the Public Sector link Who Benefits from Public Spending on Education? link Policy Instruments link Health Services link Declining Utilization link Access by the Poor link Changing Role of the Public Sector link Targeting Public Expenditures on Health link Policy Instruments link Transfers and Safety Nets link Structure of Social Protection link Who Benefits from Social Protection? link Annexes Education Data link Health Data link Contents "Poverty, Social Services, and Safety Nets in Vietnam" Figures Trends in School Enrollment, 1987−1993 link Net Enrollment Rates by Income Quintile, 1993 link Public and Private Financing of Education in Vietnam, 1993 link Per Capita Subsidies for Education, 1993 link Distribution of Subsidies for Education, 1993 link Private Cost of Public Schooling, 1993 link Affordability of Public Schooling, 1993 link Trends in Utilization of Health Services, 1987−1993 link Health Service Contact Rates by Provider and Quintile, 1993 link 10 Public and Private Financing of Health Services, 1993 link 11 Per Capita Subsidies for Health, 1993 link 12 Distribution of Subsidies for Health, 1993 link 13 Private Costs of Public Health Services, 1993 link 14 Affordability of Public Health Services, 1993 link Tables Expenditure on Pensions and Social Relief, 1994 link Distribution of Government Transfer Payments by Quintile, 1993 link Forewo rd The decade of the 1990s marks Vietnam's transition to sustained and rapid growth following the economic reforms initiated in 1989 Broad−based growth will generate new and diverse income−earning opportunities for the poor in Vietnam, but some will be unable to take full advantage of them because of illiteracy, lack of skills, ill−health and malnutrition Ensuring access for the poor to basic social services—especially primary education, basic health care and family planning is doubly essential It alleviates the immediate consequences of poverty and attacks one of its principal causes Greater investment in human capital will ensure that the poor both gain from and contribute to growth Not all the poor will benefit from these policies It may take a long time for some, such as those living in remote regions, to participate fully and the old and disabled may never be able to so Even among those who benefit, some of the poor will remain acutely vulnerable to adverse shocks from short−term stress and natural calamities These groups need to be protected by a system of targeted transfers and safety nets Vietnam has made impressive progress in providing widespread access to basic social services for a country with such a low level of income It has also developed an extensive system of social transfers and safety nets Altogether public spending on these programs absorbs around one−third of the government's discretionary current expenditure But in the late 1980s and early 1990s the quantity and quality of social service provision showed signs of deterioration Secondary school enrollments declined, and utilization of public sector health services also fell These developments occurred in parallel with major changes in the provision and financing of social services Figures "Poverty, Social Services, and Safety Nets in Vietnam" As part of Vietnam's ambitious program of structural reform, user fees were introduced for publicly−provided education and health services and private sector provision was liberalized in both sectors in 1989 This paper examines the changing role of the public sector in financing and provision of social services and safety nets, and assesses its efficiency in targeting the poor in the wake of these important policy reforms Much of the analysis draws on distributional data generated by the Vietnam Living Standards Survey of households and rural communes carded out in 1992−93 JAVAD KHALILZADEH−SHIRAZI DIRECTOR COUNTRY DEPARTMENT EAST ASIA AND PACIFIC REGION Abstract This paper examines the changing role of the public sector in financing and provision of social services and safety nets in Vietnam, and assesses its efficiency in targeting public resources to the poor in the wake of the important economic policy reforms initiated in 1989 Much of the analysis draws on distributional data generated by the Vietnam Living Standards Survey of households and rural communes carried out in 1992−93 The paper analyses the sources and uses of funds for education, health and social transfers, and highlights the emerging importance of public sector pricing policy and private out−of−pocket expenditures in social sector financing Against this background, the paper evaluates the benefit incidence of public spending in terms of the distribution of per capita subsidies and the relative shares of total subsidies accruing to different expenditure quintiles Introduction Broad−based economic growth will generate new and diverse income−earning opportunities for the poor in Vietnam, but some will be unable to take full advantage of them because of illiteracy, lack of skills, ill−health and malnutrition Ensuring access for the poor to basic social services—especially primary education, basic health care and family planning is doubly essential It alleviates the immediate consequences of poverty and attacks one of its principal causes Greater investment in human capital will ensure that the poor both gain from and contribute to growth Not all the poor will benefit from these policies It may take a long time for some, such as those living in remote regions, to participate fully and the old and disabled may never be able to so Even among those who benefit, some of the poor will remain acutely vulnerable to adverse shocks from short−term stress and natural calamities These groups need to be protected by a system of targeted transfers and safety nets Vietnam has made impressive progress in providing widespread access to basic social services for a country with such a low level of income It has also developed an extensive system of social transfers and safety nets Altogether public spending on these programs absorbs around one−third of the government's discretionary current expenditure But since the late 1980s the quantity and quality of social service provision has shown signs of deterioration Secondary school enrollments have declined sharply, and utilization of health services has also fallen These developments have occurred in parallel with major changes in the provision and financing of social services As part of Vietnam's ambitious program of structural reform, user fees were introduced for publicly−provided education and health services and private sector provision was liberalized in both sectors in 1989 This paper focuses on the access of the poor to social services which has emerged in the wake of these important reforms and its implications for the changing role of the public sector in ensuring that adequate access is consolidated and sustained It begins with an assessment of performance and policy options in education and then Abstract "Poverty, Social Services, and Safety Nets in Vietnam" turns to the health sector where the impact of reform appears to have been more far−reaching Finally the paper examines the large program of social transfers and safety nets and discusses its effectiveness and efficiency in targeting public resources to the poor Much of the paper is based on distributional data generated by the Vietnam Living Standards Survey of households and rural communes carried out in 1992−93 Annexes and document the empirical results underlying the analysis Education Falling School Enrollments Vietnam has made impressive progress in expanding access to education during the last three decades It has established a comprehensive network of educational institutions throughout the country and laid the foundation for universal primary education by placing a primary school in every commune As a result, Vietnam has achieved high levels of literacy and school enrollment relative to its per capita income level—but not relative to other East Asian countries To consolidate and sustain this progress in expanding educational opportunities, a closer watch is needed over the poor, especially over their ability to complete primary education, to receive education of acceptable quality and to have equitable access to secondary education However, there is evidence that the impressive gains achieved during the last 30 years are under serious threat A major deterioration in both schooling quantity and quality indicators has taken place during the last decade This is evident in the marked decline in school enrollments which has occurred, most dramatically in secondary schools, since the late 1980s (see Figure 1) Figure 1: Trends in School Enrollment, (in millions) Enrollments in lower secondary schools have dropped sharply, falling by around 20 percent from a peak of 3.29 million in 1987 to 2.71 million in 1990 Education "Poverty, Social Services, and Safety Nets in Vietnam" And at senior secondary level, enrollments fell even more sharply by almost 50 percent from 0.93 million in 1987 to only 0.52 million in 1991 Since the secondary school age population was increasing during this period, these declines in absolute student numbers represent an even sharper drop in secondary school enrollment rates Secondary school enrollments have risen again somewhat in the early 1990s but have not yet recovered their former levels Similar declines have taken place at all levels of post secondary education Including students enrolled in technical vocational and secondary vocational schools together with higher education (universities and colleges), overall post secondary enrollments fell by about 20 percent between 1987 and 1992 Only primary education, which experienced a slight dip in enrollments between 1987 and 1989, appears to have escaped the overall picture of quantitative decline There is also evidence of lower female enrollment at all levels of schooling, especially at the secondary and tertiary levels The explanation for this decline must lie in some change in the determinants of school enrollment Whether children enroll in school is influenced by a multitude of factors reflecting family background, expected returns to education and the costs of access to school in the community Faster economic growth means more opportunities for higher paying work and greater incentives to invest in human capital Those expected future returns, however, have to be balanced against the present costs of schooling, that is the out−of−pocket expenditures on education incurred by families for public or private schooling The full private costs of education to the family includes not only the schooling costs that are formally passed on in terms of official fees, but also the hidden costs of unofficial parental contributions, learning materials, uniforms and transportation, plus the opportunity costs of time associated with school attendance When costs are too high, the poor are less likely to continue in school The private costs of schooling may well have risen enough to keep more children out of school A nationwide system of official tuition fees for public schools was introduced in September 1989 Parents are also expected to pay contributions to parent teacher associations and to bear the cost of textbooks, clothing and food At the same time, more young people may be choosing to take advantage of the job opportunities created by the restructuring and growth of the Vietnamese economy which have raised the opportunity cost of schooling These changes in the factors determining the private costs of schooling are particularly likely to have affected poor families and they may have borne the brunt of the decline in aggregate enrollments which Vietnam has experienced Access By The Poor Averaging across all income groups about 78 percent of children age to 10, the official primary school age group, were enrolled in primary schools in 1993 Children begin to drop out of school in large numbers beyond this age group and only 36 percent of those age 11 to 14 were enrolled in lower secondary schools; however, a much higher proportion of these lower secondary school age children (69 percent) were attending some kind of school, indicating a considerable amount of overage enrollment in primary schools due to delayed entry and grade repetition More children left school in the upper secondary age group, 15 to 17 years, leaving only 11 percent of those children enrolled in upper secondary schools; again a higher proportion (26 percent) were still attending school, suggesting substantial overage enrollment in lower secondary schools Very few youths—2 percent of those aged 18 to 24—were enrolled in any kind of post secondary education, broadly defined to include technical and secondary vocational schools together with universities and colleges How large is the enrollment gap between the poor and the better off? The aggregate enrollment rates mask large differences between income groups, with the exception of primary education where a fairly high enrollment rate implies that most of the poor have access (see Figure 2) Access By The Poor "Poverty, Social Services, and Safety Nets in Vietnam" Figure 2: Net Enrollment Rates by Income Quintile, 1993 (% of target group enrolled in target level) At primary level in 1993, the net enrollment rate among the poorest quintile was 68 percent, or about 10 percent lower than the rate in the top quintile But at junior secondary level the gap widens considerably with a threefold difference between the poorest and the richest quintiles; only 19 percent of the poorest children are enrolled in lower secondary schools At upper secondary level the gap widens still further to a 15−fold difference; less than percent of the poorest 15 to 17 years old are in upper secondary school The differentials become even wider at post secondary level, where no youths aged 18 to 24 in the poorest quintile are enrolled in any kind of post secondary education compared to percent in the richest quintile Changing Role Of The Public Sector An important goal of the public sector in Vietnam's emerging market economy is to complement rather than substitute for the private sector by focusing on priority areas of government involvement where private markets cannot perform efficiently and equitably Basic education—especially primary but also lower secondary levels—is a priority area for government involvement because it provides broad benefits to society as a whole and would tend to be undersupplied, especially to the poor, without government subsidies to lower the costs of access so that it is affordable Yet in Vietnam, despite public intervention in subsidizing basic education, net enrollment rates among the poor still lag behind those achieved by the better off Indeed the quality of schooling received by the poor may lag considerably more The scope of the government's involvement in basic education is constrained by the fact that it spreads its resources thinly across all levels of the education system—including the higher levels of education which are more costly per student, can serve fewer people and which are largely used by the better off This section puts into perspective the scope and nature of public sector involvement in education relative to the role of the private sector Changing Role Of The Public Sector "Poverty, Social Services, and Safety Nets in Vietnam" Provision Of Education Up to now the Government has continued to assume virtually the entire responsibility for providing education Since 1989 private schools have been tolerated although not actively encouraged However, private schools enroll only a limited number of students Moreover, non−public schools are not entirely private Some of them are mixed schools whose operating costs are still subsidized by the Government Overall, the purely public schools enroll about 98 percent of all primary school students; this proportion is the same across the income distribution On average, the public sector also enrolls 98 percent of all lower secondary students At upper secondary level the overall public sector share declines slightly to 94 percent, falling from 100 percent of enrollments among the poorest quintile to 93 percent among the richest At post secondary level the public sector enrolls nearly all students Financing Of Education While it dominates the provision of school places, the public sector actually finances much less than this proportion of all schooling expenditures State budget subsidies for education and training are allocated broadly according to the distribution of administrative responsibilities across the main tiers of government The central government budget for the Ministry of Education and Training subsidizes the higher education institutions (universities and colleges) which it administers directly It also finances a variety of targeted education programs (a subset of the 28 national programs) which are implemented directly by local governments on behalf of the center Local government budgets subsidize the lower levels of schooling, with the provincial tier being responsible for secondary schools together with post−secondary technical and vocational training, and the district governments responsible for subsidizing the operation of primary schools Under these arrangements, the central government budget finances only one−quarter of the state budget for education, while the remaining three−quarters are spent by the local governments Overall state budget expenditures for education and training amounted to 2,700 billion dong in 1993, or about 10 percent of discretionary current expenditures (excluding interest payments) The largest share of the state budget—35 percent—is allocated to primary schools Another 29 percent of the state budget is spent on post−secondary education Most of the remaining one−third of the budget goes to secondary schools and the targeted national programs—14 percent to lower secondary schools, percent to upper secondary schools and 10 percent to the targeted programs Expenditures by the private sector have now emerged as an important complement to state budget outlays at all levels of education Estimates based on reported household expenditures from the VLSS suggest that total private spending on education amounted to about 2,050 billion dong in 1993 Almost all of this—nearly 2,000 billion dong—was spent by students enrolled in public schools Spending on textbooks—an essential input to productive schooling—absorbed around 480 billion of private outlays on public schooling Payment of official fees to public schools cost students another 270 billion dong while informal parental contributions amounted to a further 190 billion dong Private expenditures on public school uniforms totaled 290 billion dong and other school−related expenditures (transport, food and lodging and some other expenses) added another 750 billion dong to the private costs of public schooling Putting these public and private expenditures together (averaging across the 1992 and 1993 budgets to estimate public expenditures for the 1992−1993 school year) suggests that the state budget finances only 51 percent of overall education expenditures (see Figure 3) This aggregate figure masks considerable variation across levels Private outlays turn out to be larger than public subsidies for all levels of schooling except for post−secondary education Thus the state budget finances 48 percent of public primary schooling, but only 32 percent and 28 percent of lower and upper secondary schooling respectively Only at post−secondary level does the role of the state become dominant with the budget paying for 78 percent of total expenditures These figures highlight the Provision Of Education "Poverty, Social Services, and Safety Nets in Vietnam" diminished role that the public sector now plays in the financing, as distinct from physical provision, of education On the one hand this means that the education sector has been successful in mobilizing a considerable volume of private resources to finance schooling On the other hand it means that a variety of prices already play an important role in rationing access to public schooling—the prices of official fees, unofficial contributions, textbooks, uniforms, transport etc This factor is especially likely to influence access by students from poor families and may limit the scope for further cost recovery to finance expanded access and better quality of education Figure 3: Public and Private Financing of Education in Vietnam, 1993 (in billions of dong) Who Benefits From Public Spending On Education? The differentials in enrollment rates suggests the need for spending more resources on education programs which yield higher social returns and can benefit the poor more effectively: the key priority is closing the enrollment gap and raising the quality of basic education This can be achieved by directing more public spending to these programs, either by spending more on the education sector or by redirecting the allocation of resources among programs within the education budget Public expenditure choices clearly play an important role in determining the effectiveness with which the education sector as a whole reaches the poor, and how efficiently it does so In order to target the poor effectively, the allocation of public expenditures needs to give priority to subsidizing the lower levels of education which the poor are more likely to use extensively But targeting the poor efficiently also requires that they use a large share of the subsidized programs so as to minimize leakages to the better off; this means encouraging the better off to switch out of the public sector altogether Assessing how well public spending on education is targeted to the poor requires a profile of who uses publicly provided education, together with measures of the in−kind subsidy received by these users This analysis uses the VLSS data to generate the distribution of public school enrollments by per capita consumption, together with per−student subsidies estimated from the public finance data The main elements of the utilization picture are already clear In general, school enrollment rates rise with the level of per capita consumption while public sector shares are fairly constant, so public school enrollment rates also tend to be higher among the better off than the poor This enrollment gap widens considerably at higher Who Benefits From Public Spending On Education? "Poverty, Social Services, and Safety Nets in Vietnam" Trends in Utilization of Health Services, 1986−93 link Health Service Contact by Provider and Expenditure Quintile, 1993 link Utilization rates for Health Services by Quintile, 1993 link Public and Private Sector Shares of Health Service Utilization, 1993 link Average Out of Pocket Expenditure on Fees per Health Service Contact, 1993 link Average Out of Pocket Expenditure on Drugs per Health Service link Contact, 1993 Average Out of Pocket Expenditure on Fees and Drugs per Health Service Contact, 1993 link Aggregate Private Expenditure on Fees for Health Services, 1993 link Aggregate Private Expenditure on Drugs, 1993 link 10 Aggregate Private Expenditure on Health, 1993 link 11 Aggregate Public Expenditure on Health, 1993 link 12 Sources and Uses of Aggregate Health Expenditures, 1993 link 13 Public and Private Shares of Aggregate Health Financing, 1993 link 14 Public Subsidies and Cost Recovery for Public Health Services, 1993 link 15 Benefit Incidence of Public Subsidies for Health, 1993 link 16 Effectiveness of Targeting Public Subsidies for Health, 1993 link 17 Efficiency of Targeting Public Subsidies for Health, 1993 link 18 Lorenz Distributions of Public Subsidies for Health, 1993 link 19 Availability of Health Providers in Rural Areas, 1993 link 20 Distance to Health Providers in Rural Areas, 1993 link 21 Travel Time to Health Providers in Rural Areas, 1993 link 22 Official Fee Structure for Public Health Services link 23 Criteria for Exemption from Fees for Public Health Services link 24 Percent of Users Who Pay Zero per Public Sector Contact, 1993 link 25 Average Nonzero Expenditure on Health per Public Sector Contact, 1993 link 26 Affordability Ratios for Public Health Services, 1993 link 27 Probability of Consulting a Doctor per Public Health Contact, 1993 link Health Data 51 "Poverty, Social Services, and Safety Nets in Vietnam" 28 Major Health Problems in Rural Areas, 1993 link 29 Major Problems with Health Services in Rural Areas, 1993 link Table 1: Trends in Utilization of Health Services, 1986−1993 1987 1988 1989 1990 1991 1992 1993 In millions Consultations 129.718 114.999 77.893 66.904 NA 79.619 66.096 Inpatients 6.510 6.270 5.105 4.515 NA 5.207 6.427 Consult/person 2.10 1.82 1.20 1.01 NA 1.15 0.93 Inpatients/1000 105 99 79 68 NA 75 91 61.750 63.263 64.774 66.233 67.774 69.405 70.983 Rates Memo: Population (in millions) Source: Ministry of Health Table 2: Health service Contact Rates by Provider and Expenditure quintile, 1993 (percent of persons reporting ill last month who sought treatment) I II III IV V Average Urban Rural Public providers 11.5 14.3 15.5 15.9 19.5 15.4 18.8 14.5 Hospital inpatient 2.1 2.3 3.7 3.1 3.4 2.9 3.1 2.9 Hospital outpatient 3.3 4.2 5.1 7.1 12.1 6.4 11.7 5.0 Commune health center 5.7 7.0 5.7 4.6 2.5 5.1 1.9 5.9 Other clinic 0.5 0.9 1.0 1.1 1.5 1.0 2.2 0.7 Private providers 14.5 17.0 20.5 17.5 25.0 19.0 22.0 18.2 Doctor 3.7 4.7 8.6 9.6 18.2 9.1 17.1 7.0 Paramedic 10.3 11.l 11.1 7.2 6.0 9.1 3.6 10.5 Traditional healer 0.4 0.9 0.8 0.7 0.6 0.7 1.0 0.6 Other providers 0.1 0.2 − 0.1 0.3 0.1 0.3 0.1 Self−medication 70.2 66.2 62.6 65.8 54.7 63.8 58.5 65.2 No treatment 3.8 2.5 1.5 0.8 0.7 1.8 0.7 2.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 11.21 17.42 19.85 33.63 18.40 31.88 14.92 Memo: High quality providers 9.00 Health Data 52 "Poverty, Social Services, and Safety Nets in Vietnam" Table 3: Utilization Rates for Health Services by Quintile, 1993 (annualised rate per person per year) I II III IV V Average Urban Rural Public providers 0.348 0.502 0.497 0.537 0.663 0.509 0.640 0.477 Hospital inpatient 0.063 0.081 0.119 0.106 0.116 0.097 0.104 0.095 Hospital outpatient 0.098 0.146 0.164 0.239 0.411 0.212 0.399 0.165 Commune health center 0.172 0.245 0.182 0.154 0.086 0.167 0.063 0.193 Other clinic 0.015 0.030 0.033 0.038 0.050 0.033 0.073 0.023 Private providers 0.439 0.595 0.659 0.592 0.852 0.627 0.748 0.597 Doctor 0.111 0.166 0.278 0.325 0.618 0.299 0.582 0.229 Paramedic 0.313 0.391 0.356 0.242 0.204 0.301 0.121 0.346 Traditional healer 0.013 0.030 0.025 0.023 0.020 0.022 0.035 0.019 Other providers 0.003 0.008 0.000 0.003 0.010 0.005 0.010 0.003 Self−medication 2.124 2.325 2.015 2.222 1.863 2.110 1.992 2.139 Total 2.912 3.422 3.172 3.351 3.377 3.246 3.381 3.213 Average length of stay 7.600 (days per inpatient) 8.125 8.255 7.683 7.217 ? ? ? Memo: Table 4: Public and Private Sector Shares of Health Service Utilization, 1993 (percent of total) I II III IV V Average Urban Rural 100 100 100 100 100 100 100 100 Public 39 41 36 42 39 40 42 39 Private 61 59 64 58 61 60 58 61 100 100 100 100 100 100 100 100 Public 14 17 19 19 24 19 23 17 Private 86 83 81 81 76 81 77 83 Inpatient Public Outpatient Self−medication Private All services Health Data 53 "Poverty, Social Services, and Safety Nets in Vietnam" Table 5: Average Out of Pocket Expenditure on Fees per Health Service Contact, 1993 (in thousands of dong) I II III IV V Average Urban Rural Hospital inpatient 7.6 15.3 25.2 32.4 44.7 27.6 44.9 23.1 Hospital outpatient 1.8 2.1 8.3 5.3 4.7 4.8 4.4 5.0 Commune health center 0.2 0.1 0.0 0.1 0.8 0.2 0.5 0.1 Other public 0.3 1.8 0.5 3.3 3.5 2.3 1.1 3.2 Doctor 0.6 1.2 1.2 3.0 3.2 2.4 3.9 1.4 Paramedic 0.5 0.5 0.7 0.5 0.5 0.6 0.6 0.6 Traditional healer − 0.4 0.2 − 1.3 0.4 0.2 0.9 Other providers − − − 1.0 − 0.1 − 0.3 Public providers Private providers Table 6: Average Out of Pocket Expenditure on Drugs per Health Service Contact, 1993 (in thousands of dong) I II III IV V Average Urban Rural Hospital inpatient 66.7 147.2 173.9 186.1 277.2 182.9 201.8 177.8 Hospital outpatient 41.2 49.9 52.8 73.9 93.0 71.9 63.5 77.0 Commune health center 12.9 29.7 30.8 42.9 51.9 31.2 35.7 30.8 Other public 37.6 32.7 22.4 52.1 41.5 38.1 39.6 37.0 Doctor 32.6 37.4 52.0 52.2 56.7 50.9 50.1 51.4 Paramedic 16.3 21.1 33.9 42.8 49.5 30.5 38.1 29.8 Traditional healer 104.0 33.1 44.2 105.1 67.9 64.7 92.4 51.8 Other providers 15.0 6.0 − 10.0 37.0 21.2 27.0 16.6 Self−medication 10.2 12.4 15.4 19.7 25.2 16.5 18.1 16.1 Public providers Private providers Health Data 54 "Poverty, Social Services, and Safety Nets in Vietnam" Table 7: Average Out of Pocket Expenditure on Fees & Drugs per Health service contact, 1993 (in thousands of dong) I II III IV V Average Urban Rural Hospital inpatient 74.3 162.5 199.1 218.5 321.9 210.5 246.7 200.9 Hospital outpatient 43.0 52.0 61.1 79.2 97.7 76.7 67.9 81.9 Commune health center 13.1 29.8 30.8 43.0 52.6 31.4 36.2 31.0 Other public 37.8 34.5 22.9 55.4 45.0 40.4 40.7 40.2 Doctor 33.2 38.7 53.2 55.2 59.8 53.3 54.0 52.8 Paramedic 16.8 21.6 34.6 43.3 50.1 31.1 38.7 30.5 Traditional healer 104.0 33.5 44.4 105.1 69.1 65.1 92.5 52.7 Other providers 15.0 6.0 − 11.0 37.0 21.3 27.0 16.9 Self−medication 10.2 12.4 15.4 19.7 25.2 16.5 18.1 16.1 Public providers Private providers Table 8: Aggregate Private Expenditure on Fees for Health Services, 1993 (in billions of dong) I II III IV V Total Urban Rural Public providers 10 23 62 68 104 269 93 177 Hospital inpatient 18 42 49 74 190 66 125 Hospital outpatient 19 18 27 72 25 47 Commune health center 0 0 Other public Private providers 15 30 63 33 32 Doctor 14 28 50 32 18 Paramedic 12 13 Traditional healer − 0 − 1 Other providers − − − − − 29 71 84 134 331 125 210 14.20 14.18 14.21 14.20 70.98 14.16 56.82 All health services 13 Memo: Population (millions) Health Data 14.19 55 "Poverty, Social Services, and Safety Nets in Vietnam" Table 9: Aggregate Private Expenditure on Drugs, 1993 (in billions of dong) I II III IV V Total Urban Rural Public providers 157 390 505 653 1,092 2,799 728 2,071 Hospital inpatient 60 169 293 280 457 1,257 296 961 Hospital outpatient 57 104 123 251 543 1,081 359 722 Commune health center 31 103 79 94 63 371 32 339 Other public 14 10 28 30 90 41 49 Private providers 143 220 392 422 665 1,841 528 1,315 Doctor 51 88 205 241 497 1,081 413 670 Paramedic 72 117 171 147 144 652 65 587 Traditional healer 19 14 16 34 19 102 46 56 Other providers 1 − Self−medication 307 409 439 622 666 2,472 510 1,961 All health services 607 1,019 1,336 1,697 2,424 7,112 1,767 5,347 14.20 14.18 14.21 14.20 70.98 14.16 56.82 Memo: Population (millions) 14.19 Table 10: Aggregate Private Expenditure on Health, 1993 (in billions of dong) I II III IV V Total Urban Rural Public providers 167 413 567 721 1,197 3,065 821 2,248 Hospital inpatient 66 186 335 329 530 1,446 362 1,086 Hospital outpatient 60 108 142 269 570 1,150 384 768 Commune health center 32 104 79 94 64 373 32 340 Other public 15 11 30 32 96 42 53 Private providers 146 226 400 438 695 1,906 561 1,347 Doctor 52 91 210 255 525 1,133 445 688 Paramedic 75 120 175 149 145 663 66 599 Traditional healer 19 14 16 34 20 103 46 57 Other providers 1 − Self−medication 307 409 439 622 666 2,472 510 1,961 All health services 426 687 984 1,205 1,721 5,051 1,317 3,735 Memo: Health Data 56 "Poverty, Social Services, and Safety Nets in Vietnam" Population (millions) 14.19 14.20 14.18 14.21 14.20 70.98 14.16 56.82 Table 11: Aggregate Public Expenditure on Health, 1993 (in billions of dong) 1992 1993 Central Local Total Central Local Total Hospitals 153 687 840 311 1,002 1,312 Central 117 − 117 237 − 237 Branch 36 − 36 74 − 74 Provincial − 450 450 − 656 656 District − 237 237 − 345 345 Comm health centers/a − 21 21 − 31 31 Prevention 75 − 75 39 − 39 Training 32 − 32 48 − 48 Research − − Administration − − Other − − − − − − Total 265 709 974 410 1,033 1,442 Memo: 132 Off−budget expenditure on commune health centers/b /a Estimate based on number of CHWs paid by state budget /b Estimate based on total number of CHWs Table 12: Sources and Uses of Aggregate Health Expenditure, 1993 (in billions of dong) SOURCES: Public USES: Private: All sources Fees Drugs Total Public 1,442 269 2,799 3,065 4,507 Hospitals 1,312 262 2,338 2,600 3,912 Health centers 31 371 373 404 Prevention 39 0 − 39 Other 60 90 95 155 Health Data 57 "Poverty, Social Services, and Safety Nets in Vietnam" Private − 63 4,313 4,377 4,377 Providers − 63 1,841 1,906 1,906 Self−medication − − 2,472 2,472 2,472 All uses 1,442 331 7,112 7,442 8,884 100 105 125 Memo: Per capita 20 (in thousands of dong) Table 13: Public and Private Shares of Aggregate Health Financing, 1993 (as percent of aggregate expenditure) SOURCES: Public Private: USES: All sources Fees Drugs Total Public 16.2 3.0 31.5 34.5 50.8 Hospitals 14.8 2.9 26.3 29.3 44.0 Health centers 0.4 0.0 4.2 4.2 4.5 Prevention 0.4 − − − 0.4 Other 0.7 0.1 1.0 1.1 1.7 Private − 0.7 48.5 49.3 49.3 Providers − 0.7 20.7 21.4 21.4 Self−medication − − 27.8 27.8 27.8 All uses 16.2 3.7 80.1 83.8 100.0 Table 14: Public Subsidies and Cost Recovery for Public Health Services, 1993 (in thousands of dong) Total: Per unit: Cost Utilisation Costs/a (millions) (billions) Fees Subsidy (billions) (billions) cost (thous) subsidy (thous) recovery (%) Hospital inpatients 6.874 999 190 809 145 118 19 Central 0.338 172 33 140 511 414 19 Provincial 3.300 558 106 452 169 137 19 District 2.765 188 36 152 68 55 19 Branch 0.471 81 15 65 171 138 19 Hospital outpatients 15.039 575 72 504 38 33 12 Health Data 58 "Poverty, Social Services, and Safety Nets in Vietnam" Central 1.821 111 14 97 61 53 12 Provincial 4.970 234 29 205 47 41 12 District 7.350 221 27 193 30 26 12 Branch 0.898 10 11 10 12 Comm health centers 11.887 165 31 14 /a Hospital costs based on econometric estimates of hospital marginal costs Table 15: BENEFIT INCIDENCE OF PUBLIC SUBSIDIES FOR HEALTH, 1993 (in thousands of dong per capita) I II III IV V Average Urban Rural Hospital inpatients 7.4 9.5 14.0 12.5 13.6 11.4 12.2 11.2 Hospital outpatients 3.3 4.9 5.5 8.0 13.8 7.1 13.4 5.5 Commune health centers 0.4 0.6 0.5 0.4 0.2 0.4 0.2 0.5 All public programs 11.2 15.0 19.9 20.9 27.6 18.9 25.7 17.2 541.9 802.3 1,064.6 1,492.4 3,203.1 1,475.9 Memo: Per capita consumption 2,406.4 1,156.5 Table 16: Effectiveness of Targeting Public Subsidies for Health, 1883 (percent of per capita consumption expenditure) I II III IV V Average Urban Rural Hospital inpatients 1.4 1.2 1.3 0.8 0.4 0.8 0.5 1.0 Hospital outpatients 0.6 0.6 0.5 0.5 0.4 0.5 0.6 0.5 Commune health centers 0.1 0.1 0.0 0.0 0.0 0.0 0.0 0.0 All public programs 2.1 1.9 1.9 1.4 0.9 1.3 1.1 1.5 541.9 802.3 1,064.6 1,492.4 3,203.1 1,475.9 Memo: Per capita consumption (in thousands of dong) Health Data 2,406.4 1,156.5 59 "Poverty, Social Services, and Safety Nets in Vietnam" Table 17: Efficiency of Targeting Public Subsidies for Health, 1993 (percent of aggregate public expenditure on health) I II III IV V Average Urban Rural Hospital inpatients 13 17 24 22 24 100 21 79 Hospital outpatients 14 15 23 39 100 38 62 Commune health centers 20 29 22 18 10 100 92 All public programs 12 16 21 22 29 100 27 73 11 15 21 46 100 Memo: % of aggregate consumption Table 18: Lorenz Distributions of Public Subsidies for Health, 1993 (cumulative, percent of, aggregate public subsidies for health) I II III IV V Hospital inpatients 13 30 54 76 100 Hospital outpatients 23 39 61 100 Commune health centers 20 50 71 90 100 All public programs 12 28 49 71 100 % of population 40 60 80 100 % of aggregate consumption 18 33 54 100 Memo: Table 19: Availability of Health Providers in Rural Areas, 1993 (percent of persons with provider available in the commune) I II III IV V Average Hospital 12 Dispensary 26 29 33 40 47 33 Pharmacy 63 66 72 78 87 71 Clinic 94 95 96 94 94 95 Doctor 40 42 40 58 60 46 Physician 97 100 100 100 100 99 Nurse 95 97 96 95 95 96 Pharmacist 67 63 63 67 71 66 Midwife 93 91 92 93 95 93 Health Data 60 "Poverty, Social Services, and Safety Nets in Vietnam" Bonze 92 95 94 97 100 95 Healer 75 75 75 84 90 79 Table 20: Distance to Health Providers in Rural Areas, 1993 (distance if provider not available in the commune; in kilometers) I II III IV V Average Hospital 11.32 10.35 10.54 9.36 10.34 10.44 Dispensary 7.2 7.0 7.1 6.3 8.2 7.1 Pharmacy 9.2 8.3 8.6 8.6 7.7 8.7 Clinic 8.0 7.7 5.7 4.1 4.0 6.2 Doctor 7.2 7.4 7.5 6.7 6.7 7.2 Physician 8.0 8.0 8.0 8.0 NA 8.0 Nurse 4.4 8.1 8.2 4.5 1.7 5.5 Pharmacist 7.5 7.5 8.1 6.8 6.2 7.4 Midwife 3.5 5.8 7.1 5.8 3.8 5.4 Bonze 7.0 7.8 9.0 10.0 8.1 8.0 Healer 10.3 8.8 9.4 8.3 7.9 9.2 Table 21: Travel Time to Health Providers in Rural Areas, 1993 (travel time if provider not available in the commune; in hours) I II III IV V Average Hospital 2.6 2.4 2.4 2.1 2.3 2.4 Dispensary 1.7 1.6 1.7 1.5 1.8 1.7 Pharmacy 2.1 2.0 2.1 2.0 1.8 2.0 Clinic 1.9 2.0 1.4 0.9 0.9 1.5 Doctor 1.8 1.9 1.8 1.7 1.6 1.8 Physician 1.5 1.5 1.5 1.5 NA 1.5 Nurse 1.0 1.9 1.9 1.1 0.5 1.3 Pharmacist 1.7 1.8 1.9 1.6 1.4 1.7 Midwife 1.1 1.6 1.8 1.3 0.8 1.4 Bonze 1.5 1.9 2.1 2.3 1.8 1.8 Healer 2.4 2.1 2.2 1.9 1.6 2.1 Health Data 61 "Poverty, Social Services, and Safety Nets in Vietnam" Table 22: Official Fee Structure for Public Health Services (in dong) Consultation fee Fee per inpatient bed−day − Internal medicine 500 1,000 1,200 1,500 − Obstetric surgery & intensive care 500 1,000 1,500 2,000 − Internal medicine 500 800 1,000 − Obstetric surgery & intensive care 500 1,000 1,200 District hospitals 300 500 Central hospitals Provincial hospitals 1,500 Source: Interministerial Circular Letter Guiding the Implementation of the Council of Ministers on the Partial Collection of Users' Fees in Health services, No 14 TTLB, Hanoi, June 15, 1989 Table 23: Criteria for Exemption from Fees for Public Health Services − Those who rendered meritorious services to the revolution and who receive monthly allowances − Parents or spouse of children of war dead who receive monthly allowances − Handicapped, orphans and unaided elderly − TB, mental and leprosy patients − Ethnic minorities living in mountainous areas (at discretion of provincial people's committee) − Workers in new economic zones who receive monthly allowances − Public employees, pensioners, disabled, cadres of communes/wards, armed forces, pupils and students of vocational schools − Parents, spouse or dependents aged [...]... 0.140 450 Social evils 70 − − Total 5,074 5.195 − Transfers And Safety Nets 27 "Poverty, Social Services, and Safety Nets in Vietnam" The social security program is long−standing, dating back to 1947 Originally social security was restricted to public sector employees, but in 1993 Decree 43 CP expanded coverage to include private enterprises, joint ventures and workers in Economic Processing Zones... in Indonesia, 63 in China and 141 in Thailand Similarly, Vietnam' s hospital bed ratio of one per 389 persons compares favorably with one per 465 in China, 665 in Thailand and 1,743 in Indonesia However, beginning with reunification and accelerating during the 1980s, the health sector has come under pressure and some performance indicators have deteriorated sharply The symptoms of decline are seen in. .. services—rising from 3 thousand dong per visit at commune health centers, to 33 thousand dong per outpatient visit and 118 thousand dong per inpatient stay in hospitals In fact these average Targeting Public Expenditures On Health 19 "Poverty, Social Services, and Safety Nets in Vietnam" Figure 10: Public and Private Financing of Health (in billions of dong) figures for hospitals mask a much steeper gradient in. .. phased in gradually, with incremental budgetary spending of around 40 billion per year Transfers And Safety Nets Structure Of Social Protection Vietnam has a very extensive program of social protection funded directly through the government budget and administered jointly by the Ministry of Labor, Invalids and Social Affairs (MOLISA) and the Vietnam Confederation of Labor (VCL) In 1992 outlays on social. .. persons in each quintile (see Figure 11) Not surprisingly since hospitals dominate public Targeting Public Expenditures On Health 20 "Poverty, Social Services, and Safety Nets in Vietnam" expenditure, most of the health subsidies accruing to the poor are delivered through the hospital system, especially through inpatient care In 1993, the per capita subsidy for hospital inpatient care averaged 11 thousand... link 32 Access to Public Schools While Enrolled, 1993 link 33 Quality of Schooling in Rural Areas link Education Data 31 "Poverty, Social Services, and Safety Nets in Vietnam" 34 Most Important Reasons for not Attending School in Rural Areas link 35 Most Important Problems with School in Rural Areas link Table 1: Trends in School Enrollments, 1987−93 (in millions) 1987 1988 1989 1990 1991 1992 1993 Primary... paying nothing for drugs compared to none of the better off users Within the hospital system, a significant proportion of users still pay nothing for fees but most people pay for drugs and these ratios are not much different whether patients are poor or rich Lowering Distance 24 "Poverty, Social Services, and Safety Nets in Vietnam" Figure 13: Private Costs Of Public Health Services, 1993 (in thousands... determines how much parents are asked to pay, and investment expenditures determine the density of school placement The benefit side is influenced by the quality of schooling which also depends directly on how much the government spends on subsidizing schooling inputs such as trained teachers, textbooks and other classroom supplies Increasing Availability Vietnam has already succeeded in lowering and. .. disproportionately Improving Quality 15 "Poverty, Social Services, and Safety Nets in Vietnam" Figure 8: Trends in Utilization of Health Services, 1987−1993 Little is known about the causes underlying the apparent decline in service utilization One factor may be the deterioration in quality of government health services resulting from the compression of public expenditures in the late 1980s A large... persons living in households that receive government transfer payments Source: VLSS Households were asked whether they received any social funds from the government, and if so whether they were payments for pension and disability or for "other social subsidies" (which may correspond to spending on social Who Benefits From Social Protection? 29 "Poverty, Social Services, and Safety Nets in Vietnam" relief)